Provider Demographics
NPI:1982009569
Name:WILSON, SHANE MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:MICHAEL
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:938 WRENS ROOST CIR
Mailing Address - Street 2:2
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-0510
Mailing Address - Country:US
Mailing Address - Phone:205-544-4318
Mailing Address - Fax:
Practice Address - Street 1:938 WRENS ROOST CIR
Practice Address - Street 2:2
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-0510
Practice Address - Country:US
Practice Address - Phone:205-544-4318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-25
Last Update Date:2014-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1368111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALU67979Medicare UPIN